As people get older, they become more likely to have difficulty walking independently, and the risk of falls increases. The appropriate use of walking aids can help provide stability and safety in some elderly people with mobility problems. Mobility aids include canes, crutches, and walkers.
Using a cane correctly will help to improve balance by widening the base of support and by providing additional sensory input. The usual base of support is the area under and between the two feet. This area of support is enlarged with the use of a cane. A cane can also reduce the amount of weight that must be borne by the legs, which can be important in people with arthritis or weakness of the legs. There is good evidence to support the use of a cane in elderly people with decreased vision, peripheral nerve problems, previous stroke, as well as those who have had surgery for a hip fracture. Some patients may be reluctant to start using a cane, as they fear it makes them look frail. Consistent encouragement and emphasizing that using the cane will allow them to walk farther and more safely can usually overcome this hurdle.
Single point wooden canes, while relatively inexpensive, must be carefully fitted to the correct size relative to the patient’s height and arm length. Lighter weight aluminum canes can easily be adjusted for proper height. The length of the cane should ideally result in between twenty and thirty degrees of elbow flexion. This can be achieved by measuring from the floor to the wrist crease, with the arm hanging loosely at the patient’s side. The cane should be held in the hand opposite to the impaired (weak or painful) leg, and moved forward with the impaired leg. By doing this, the amount of weight bearing experienced by that leg is reduced proportionate to the amount of weight put through the cane.
Canes should always be fitted with rubber tips, to prevent slipping. The standard cane has a smooth, curved handle. A built-up molded handle is used in people with impaired hand function, for example in severe arthritis. Multiple point canes, such as quadruped canes (commonly called quad canes), provide a greater base of support and thus even greater stability, and can stand by themselves. They are often prescribed in stroke patients. However, they are cumbersome and difficult to use on uneven surfaces or by people who move relatively quickly, as all four feet must be on the ground at the same time else the increased base of support is lost and the extra feet may get entangled in furniture. A straight cane has the advantage of being maneuverable in tight quarters.
Bilateral crutches are infrequently used in older adults to eliminate weight bearing on one leg. Crutches are made of either aluminum or wood, and are adjustable in height at the base and hand piece. The top bar should be two inches below the armpit, and the hand pieces should allow a fifteen-degree angle at the elbow. Crutches require considerable balance, strength, and coordination (for proper sequencing of crutches and legs) to use safely, and have been associated with injury to the axillary artery. As crutches are often too difficult for older persons to use, walkers are generally preferred when weight bearing is only permitted on one leg.
A walker provides a movable stable platform that increases the base of support anteriorly and laterally, greater than that provided by a cane. Walkers are indicated for poor balance in general, as well as for bilateral leg problems (where one would otherwise have difficulty deciding in which hand to carry a cane), to achieve non-weight bearing status for one leg, for those afflicted with Parkinson’s disease, and to transmit weight through the arms rather than through a painful spine. Walkers are made of aluminum and are adjustable in height. Many can be easily folded up when not in use. There are three main types of walkers: standard, front-wheeled, and four-wheeled. Patients whose grip is impaired from weakness or arthritis, can lean on a forearm-support walker with their forearms.
Standard walkers. A standard or pick-up walker is a metal, four-legged frame with rubber tips, which must be lifted and moved forward with each step or two. This type of walker is used when maximum assistance with balance is required or when restrictions on weight bearing are present. While easier to use than a cane, this style of walker does require some degree of upper body strength and cognitive ability to use safely, and results in a fairly abnormal gait.
Front-wheeled walkers. For people who have weak arms or a tendency to fall backward, a walker with wheels on the front two posts can be used. This type of walker promotes a forward displacement of the center of gravity and allows a more normal gait, as the person can continue walking without stopping to lift the walker. The front-wheeled walker is particularly useful in patients with Parkinson’s disease, as it reduces the risk of falling backwards. In addition, it is less likely to allow the patient to pick up speed as he goes along, relative to the four-wheeled walker.
Four-wheeled walkers. The most normal gait is seen when using a four-wheeled walker. While easiest to use of the three types, they also provide the least stability. Wheeled walkers for use in the community can be equipped with hand brakes, baskets for shopping, and a seat that allows the person to stop and rest. However, the user must be capable of learning to apply the brakes in order to use them safely.
Unlike canes, which must be moved in correct sequence relative to the legs, walkers generally require less instruction to use effectively, and can be ideal in older adults with mild to moderate cognitive impairment and balance or strength problems. Some instruction is necessary so that the walker is not used in an attempt to get up out of a chair. Advanced cognitive impairment can make the proper use of a walker impossible, and may be best managed by human assistance for ambulation. Disadvantages of walkers are that they require more space in which to maneuver than a cane, they may not roll well on carpeting, they make crossing thresholds difficult, and they can not be used on stairs. The use of any walking aid, in particular walkers, results in a slower gait speed and requires considerably more energy and cardiovascular fitness than walking unassisted.
See also Arthritis; Balance and Mobility; Home Adaptation and Equipment; Rehabilitation.
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Bohannon, R. W. ‘‘Gait Performance with Wheeled and Standard Walkers.’’ Perceptual and Motor Skills 85 (1997): 1185–1186.
Fishburn, M. J., and de Lateur, B. J. ‘‘Rehabilitation.’’ In Geriatrics Review Syllabus, 3d ed. Edited by D. B. Reuben, T. T. Yoshikawa, and R. W. Besdine. Dubuque, Iowa: Kendall/Hunt Pub. Co., 1996. Pages 93–103.
Kumar, R.; Roe, M. C.; and Scremin, O. U. ‘‘Methods for Estimating the Proper Length of a Cane.’’ Archives of Physical Medicine and Rehabilitation 76, no. 12 (1995): 1173–1175.
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Rush, K. L., and Ouellet, L. L. ‘‘Mobility Aids and the Elderly Client.’’ Journal of Gerontological Nursing 23, no. 1 (1997): 7–15.
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